It’s an interesting provocation! Having spent the early part of my career in health care and policy, I think it would be analytically useful in drawing the analogy to separate the problem into two policy buckets
1. Cost issues related to supply constraints that can be removed or relaxed (more directly comparable to YIMBY)
2. Market structure problems (more about the endemic market failures in virtually every part of this… 11-sided market? This set of problems feels a departure from YIMBY)
I think the bigger challenge to this idea, though, is the political economy math being wildly different. ACA as a case study shows you more or less need a critical mass of interests (eg, hospitals, insurers, doctors) on board to get anything done federally, and you basically can only win if you pick one or two “policy losers” at max.
For prior art, I recommend reading Health Affairs! Lots of deep weeds there.
One place to look is here in Korea. Friends and I have tried to theorize why it seems to be so affordable and high-quality. The thing I do know is that I never fear going into a doctor's office or hospital for even the slightest thing. I'll get quick, effective treatment at very low cost.
I wish I knew how they do it. I know it could be better still, but it's already like nothing an American--or my fellow Canadians--can even believe is possible.
Is it true for the big ticket items too? (Cancer treatment? Any personalized medicine, stem cells, etc? How much to pay and long is the wait to get an MRI?)
How's the compensation for the workers? (Housing crisis in Korea is pushing up cost of living I assume.)
Also it would be interesting to look at the lifestyle baseline for Korea vs other countries, and how many times they even utilize the services.
Hi, Pas. Let me refer you to ChatGPT for a five-point answer, but then I will elaborate myself on #3:
1. Big-ticket items like cancer treatment?
Yes, most cancer care is heavily subsidized under Korea’s National Health Insurance (NHI), especially after diagnosis. Co-pays drop significantly (sometimes to around 5%) for critical diseases like cancer, stroke, or rare conditions. You’ll still pay out of pocket for some services — especially private rooms, some imaging, or newer experimental therapies — but it’s a fraction of what you'd pay in the U.S. And you don’t get bankrupted by treatment.
2. High-tech / personalized medicine?
That’s where things get murkier. Cutting-edge treatments like stem cells or genetic therapies usually aren’t covered unless they’re formally approved and adopted into the national guidelines. So if someone wants next-gen, private-sector options, they may need to go outside the public system — and costs rise quickly in that case.
3. MRI cost and wait times?
An MRI in Korea can cost anywhere from $50 to $150 USD with insurance. Wait times are often short. I’ve had scans scheduled same-day or within a couple of days, especially if the doctor deems it urgent. In a major hospital, maybe a week — but rarely the kind of months-long delays you hear about elsewhere.
4. Compensation for medical staff?
This is a big tension point. Korean doctors are well-trained and work incredibly hard, but general practitioners and residents are not compensated the way they are in places like the U.S. or Japan. Long hours, relatively modest pay (especially early on), and rising living costs — yes, especially housing — are a growing source of burnout. There's ongoing debate and even protests about reforming medical school quotas and redistributing care to rural areas.
5. Utilization and lifestyle context?
This part is fascinating. Koreans go to the doctor a lot — one of the highest outpatient visit rates per capita in the OECD. A mix of low cost, easy access, and cultural comfort with regular checkups or even walk-ins contributes to that. So yes, the lifestyle baseline is different. And while access is high, lifestyle-related diseases (e.g., metabolic issues from long hours and convenience food) are rising.
As for #3, I have had at least a couple MRIs and CT scans, and they were all under 100 bucks, I'm sure. I always walk in off the street, and I am seen within 30 minutes if it's busy, usually quicker. There are just so many doctor's offices, mid-sized clinics or "hospitals," and the full-on hospitals.
At a regular clinic (while there are 3-4 places right in the same building or adjacent buildings), I walk in because I have a shoulder problem, say. They take my name, I sit, I go in to see the doctor within 5-10 minutes. He asks me about it, checks it out, then orders an X-ray. I go down the hall to where they have the machine as the nurse gets me X-rayed. I wait another 5-10 minutes, and then I go in and he tells me what's up. He might send me to physiotherapy right then and there--in another room. I pay 12 bukcks and leave. Oh, not without my prescription, which I take to the pharmacy downstairs. I get medicine for a few days. 8 bucks, maybe.
At a mid-sized "hospital" specializing in bones, I went in a couple years ago for my left knee. There's been some bump-thing on it since university days, and it bothers me only sometimes. But lately, it had been to where I thought I might need surgery. I walk in--off the street, no appointment--give my name, wait 20 minutes or so, and then see the guy. He orders an X-ray (or MRI??), I go down, wait a bit, get it, then wait again and see him once more. (There are about 100 people or so in the whole place, and they are all being circled around efficiently to different stations of sorts, so this is a but more waiting than at a smaller clinic.) Then I'm in, and he's telling me I have bipartate patella (knee is in two parts rather than a single bone), have always had this, and that it's fine, yet I could do some options of surgery if I like. I got some medicine and the pain went away over some time. That one didn't cost me more than 100 dollars, I'm sure.
As for definite MRI and CTs, I do recall for various things being in a whirring machine for my head (MRI), and CT scans for my stomach (and maybe other things. My wife knows more about my history than I do due to my aging and muddled memory combined with everything always being in Korean.) But it's never more than a couple hundred dollars with the most extensive tests, consulting, and treatment.
Again, I do not know how it all works, and they have achieved sime kind of excellent balance of free markets and government, but I expect if all the related markets in healthcare were freer, it would be even better. But as is, it is state of the art and affordable.
Dentist's, too. I go there and get the most high-tech treatment I've seen. I get regular cleanings for 15 bucks (with an appointment!). Afterward, they go through my X-rays (oh, yes, X-rays just before cleaning) and tell me what's going on, making some recommendations, which I can take or leave.
I simply do not worry about healthcare. I will go in for anything without fear of cost. it's all upside, as the initial consulting and testing is gonna be nothing which puts me out in any significant way.
As for Point 5, I can attest that yes, people are in all the time. I think it's partly the volume that allows all these places to stay in business, making small "sales" on people coming in for everything and paying peanuts. 23 years ago, when I first came here, I was always alarmed when students would say that on the weekend they had been to the "hospital." I was always like, "Oh, dear! What happened?" "I had a cold." They just mean that they went to the doctor's office. But that's it. They go there for colds, cuts, whatever pain, etc. I can walk in with an upset stomach due to food poisoning (I'm sometimes a miss on some shellfish!) and find myself on an IV for an hour within minutes. Go off home feeling better and 15 bucks lighter in the pocket.
I don't know what else to tell you. I'm almost always off the street, no phone-in or appointment. It's always top notch, and it's always affordable. It is literally unbelievable to Canadians. Healthcare is the least of my worries in Korea.
It was very interestingly rambling :) Thanks for the details!
So I assume it's subsidized heavily, co-pays are low, but not zero, and somehow it seems the capacity is well above utilization (so queues don't really have a chance to form, or back up).
Despite a shift toward greater public funding—with public expenditure comprising 64.4% of total spending in 2020—OOP payments still accounted for 35.6%, remaining above the OECD average. Individuals aged 60 and above contributed to 51.3% of total expenditures.
The South Korean system is funded through contributions that are proportional to taxpayers’ wages, with the current contribution rate standing at 6.67 percent of monthly income, slightly up from previous years.
[...] high doctor-to-population ratio with 2.6 doctors per 1,000 people as of 2023, which represents an increase that improves access and reduces wait times. Hospital bed availability is also notable at 12.3 beds per 1,000 people, one of the highest rates globally, reflecting the country’s readiness to manage both acute and long-term care needs.
[...] Its infrastructure ranking remained at 31st, in part because the country is wasting excess hospital capacity but also lacks enough primary care doctors.
Yes! One of the obvious problems is the artificial constraints on the supply of doctors. This includes limited residency slots, certification of immigrant doctors who studied abroad, the requirements for entering medical school (why do you need a pre-med degree?) etc.
Of course there are many other issues but it seems obvious that these artificial constraints on the supply of doctors increase the price of their services.
Two important places to start: 1- serious long-term health insurance (as you suggested)
2- some kind of collective (as opposed to the G word) action to get the healthcare system to pay its own people better and give them better physical/mental support and working conditions. They constitute almost 15% of the US workforce, and are mostly (yes, not the folks at the top - not just insurance but also "nonrofit" hospital systems) underpaid and stressed out. Use the cost-savings of AI to treat caregivers better, and they will treat patients better and stick around longer. This could be as positive and norm-setting a move as Henry Ford's paying his car workers $5 an hour...
> Use the cost-savings of AI to treat caregivers better [...]
Can you give examples of cost-savings due to AI?
It seems that the fundamental problem of more demand for healthcare vs. cost of healthcare is not really solvable without either drastically increasing the productivity of the providers and/or reducing the demand (through magical "lifestyle" changes - ie. more walking less driving, more veggies fewer calories, more fasting less feasting, more comfort less comfort food -- and all of this kind of depends on having disposable income, the financial freedom factor of fitness, healthy wallets healthy voters, woah, I know).
Yes, which is why I'm suggesting that the HC ecosystem start with its own people - employees, not just patients! And meanwhile, AI can indeed save costs and improve efficiency for a lot of routine tasks, freeing the employees to focus on the meaningful, human-centered part of their jobs. For examples, look at HC use of AI in all kinds for routine tasks, from logistics to scheduling to EHR analysis (presented to clinicians who still make decisions and talk with patients). And AVOID automated claim denials :)
I started a substack and I plan to continue writing about this. I am preparing for my dissertation defense now so I do not have a lot of time to write now but I plan to lay out how the healthcare system is designed to stifle creative destruction and then ultimately what can be done about it.
I think you're right that medicine needs voices that call specifically for freedom to exchange services. The root of it is deeper than cost issues, dismantling of doctor/patient relationships, and obfuscation of the typical supply-and-demand economies by insurance and regulation. There is also a real doctor shortage. There are controls on new practices - who can open them where they can be opened. There are issues with licensing (and over licensing). Plus all of the your list above, Jason. The regulation on the medical complex in the US is truly mind boggling.
However, a major, overarching issue is that most people are arguing from a pragmatic perspective for some version of more or less government involvement in healthcare because:
1. They don't believe that consumers of health care behave (or would or can behave) as consumers in other industries. They think there is something fundamentally different about the need for healthcare that changes this equation.
2. The moral argument for freedom of exchange (between doctors and patients and any other healthcare actor from all 11 sides of the market--as Dave G said) always bumps up against the question of how we take care of poor people.
I think we really have to start showing how patients, doctors, drug companies--all of us including poor people--are hurt in myriad ways by the status quo.
The entity mostly responsible for dismantling the doctor-patient relationship has been Government Intervention.
At the time of WW2, the government under president Roosevelt instituted a freeze on wages. Health insurance became an important part of bargaining for employees' benefits.
The employers started to offer insurance coverage. When people left their jobs, if they had medical conditions, became uninsured. The government took more control with the institution of Medicare and Medicaid in the 60ties. The prices escalated and we got the DRGs (diagnosis-related groups, with caps on payments.)
Today we have ICD10 codes which are so complicated that new categories of jobs have been created to get them right. Often doctors and Hospitals do not get paid because of it. The hospitals want to discharge patients before the money (from the DRG fixed price) runs out. To this end, they hire hospitalists, intensivists, etc, who take over patients’ care the moment they set foot in the hospital.
Today the average patient is cared for by a concierge doctor when the patient is well. (doctors are so busy with managed care and mandatory electronic medical records they cannot even talk to patients, let alone examine them.) As soon as the patient sets foot in the hospital, a doctor who doesn’t know him from Adam takes over his care to make sure that costs are contained.
As a cardiologist, this happened often to my patients, who desperately called me to the hospital to take care of them (which I did without a concierge price)
This is very simplified, but make no mistakes, government regulations are the source of this evil, not insurance companies or employers.
You’re absolutely right about the end-of-life expenses. This is a consequence of the detachment of the payer from the consumer, originating from the above-described mess.
As a co-founder of AFCM (American for Free Choice in Medicine) I’ll be happy to discuss more.
Yes!! I’ve been one campaigning against the worst inefficiencies of the system!
In fact, I just published an article making the case for investment in digital infrastructure as a way to both reduce administrative bloat, and improve patient experience/health outcomes.
Another commenter mentioned Korea, they have a nationalized health app which consolidates health records and information. Anyone is able to view their record, and it is accessible to pharmacists, clinicians, billing… everyone who would need it. Similar infrastructure exists in Denmark, and Portugal.
I’ve been calling out the fragmentation of EHR in the US, and how the CURES act and TEFCA sound like we’re moving in the right direction, but don’t incentivize the things we really need.
Great to hear other people talking about this, look forward to reading more of your work!
Not “surely” at all! I think socialized medicine might be more efficient than what we have today (which is the worst of both worlds) but a true free market would be far better
I came to the comment section to explain why I think there is no healthcare equivalent of yimby, but this is the perfect example.
Left and right leaning yimbys agree that any nearly kind of new housing is an improvement. Their differences exist but are less important. Left and right leaning healthcare reformers pull in opposite directions.
I don't think you want to go "true free market" in healthcare. It'll result in zero treatment options for people with diseases that are rare enough that there's either no value in even offering them, or the result will be too expensive for the majority of patients.
A free and competitive market would drive down costs and expand access as much as it is possible to do in the current economy, with current technology. I think you would be surprised how far that goes. For the small minority remaining who can't afford medical care, you can help them out directly. Subsidize demand if you must, but don't restrict supply.
Does "free market" mean no social support for people to get healthcare? I interpret Jason's comment as removing the intermediaries between providers and people, let the prices do their work on the supply side.
And of course if there are unexpectedly (!) magically (!!) somehow (!!??) still poor people then that's a social safety net question, there are still taxes and unemployment benefits, public funded basic research, orphan disease programs, and so on. (And there are unfortunately still death panels, after all there is going to be more demand than supply, but it would be better if insurers wouldn't have to do this implicitly through "hey, we really believe in people getting better, so here's hoping that God will fix your Type1 in 30 days, because we're not covering it more, xoxo".)
### Rethinking Healthcare: The Singapore Model and the Burden of Longevity
I believe that the current health insurance system is fundamentally flawed and in need of a complete overhaul. A more effective approach would be to adopt the Singapore model, which emphasizes mandatory savings coupled with price transparency. This system should be tempered with means-tested top-ups to the savings accounts of working-class individuals, as well as some form of emergency support. This layered approach ensures that individuals are primarily responsible for their healthcare costs, while also providing a safety net for those in need.
In this model, personal savings should form the backbone of healthcare financing for most middle-class people. The Singaporean system has demonstrated that this approach can lead to lower healthcare spending as a percentage of GDP, while still achieving a high life expectancy.
However, I must admit to a somewhat controversial perspective: I believe that people, on average, live too long. Most individuals over the age of 55 rarely contribute anything significant to civilization. By forcing people to save for their healthcare, we can mitigate the burden that the elderly place on their fellow citizens. This approach not only promotes personal responsibility but also ensures that the resources of the younger, more productive members of society are not unduly taxed to support those who are no longer contributing to the betterment of society.
Optimism is the key to unlocking a healthier future, and optimistic leadership must rise to meet the challenge of transforming healthcare. We need bold voices to say "yes" to access, affordability, and patient empowerment. This field is wide open for infectious optimists to step in, shift the narrative, and build a system worthy of our highest hopes.
There are and have been a lot of people lobbying for disconnecting health insurance and employment. I think you’ll find them in the category of “progressives” or “liberals”.
So to answer your question of “where are they” the answer is “right here all along”.
So maybe the next obvious question is an important one.
It’s an interesting provocation! Having spent the early part of my career in health care and policy, I think it would be analytically useful in drawing the analogy to separate the problem into two policy buckets
1. Cost issues related to supply constraints that can be removed or relaxed (more directly comparable to YIMBY)
2. Market structure problems (more about the endemic market failures in virtually every part of this… 11-sided market? This set of problems feels a departure from YIMBY)
I think the bigger challenge to this idea, though, is the political economy math being wildly different. ACA as a case study shows you more or less need a critical mass of interests (eg, hospitals, insurers, doctors) on board to get anything done federally, and you basically can only win if you pick one or two “policy losers” at max.
For prior art, I recommend reading Health Affairs! Lots of deep weeds there.
One place to look is here in Korea. Friends and I have tried to theorize why it seems to be so affordable and high-quality. The thing I do know is that I never fear going into a doctor's office or hospital for even the slightest thing. I'll get quick, effective treatment at very low cost.
I wish I knew how they do it. I know it could be better still, but it's already like nothing an American--or my fellow Canadians--can even believe is possible.
Is it true for the big ticket items too? (Cancer treatment? Any personalized medicine, stem cells, etc? How much to pay and long is the wait to get an MRI?)
How's the compensation for the workers? (Housing crisis in Korea is pushing up cost of living I assume.)
Also it would be interesting to look at the lifestyle baseline for Korea vs other countries, and how many times they even utilize the services.
Hi, Pas. Let me refer you to ChatGPT for a five-point answer, but then I will elaborate myself on #3:
1. Big-ticket items like cancer treatment?
Yes, most cancer care is heavily subsidized under Korea’s National Health Insurance (NHI), especially after diagnosis. Co-pays drop significantly (sometimes to around 5%) for critical diseases like cancer, stroke, or rare conditions. You’ll still pay out of pocket for some services — especially private rooms, some imaging, or newer experimental therapies — but it’s a fraction of what you'd pay in the U.S. And you don’t get bankrupted by treatment.
2. High-tech / personalized medicine?
That’s where things get murkier. Cutting-edge treatments like stem cells or genetic therapies usually aren’t covered unless they’re formally approved and adopted into the national guidelines. So if someone wants next-gen, private-sector options, they may need to go outside the public system — and costs rise quickly in that case.
3. MRI cost and wait times?
An MRI in Korea can cost anywhere from $50 to $150 USD with insurance. Wait times are often short. I’ve had scans scheduled same-day or within a couple of days, especially if the doctor deems it urgent. In a major hospital, maybe a week — but rarely the kind of months-long delays you hear about elsewhere.
4. Compensation for medical staff?
This is a big tension point. Korean doctors are well-trained and work incredibly hard, but general practitioners and residents are not compensated the way they are in places like the U.S. or Japan. Long hours, relatively modest pay (especially early on), and rising living costs — yes, especially housing — are a growing source of burnout. There's ongoing debate and even protests about reforming medical school quotas and redistributing care to rural areas.
5. Utilization and lifestyle context?
This part is fascinating. Koreans go to the doctor a lot — one of the highest outpatient visit rates per capita in the OECD. A mix of low cost, easy access, and cultural comfort with regular checkups or even walk-ins contributes to that. So yes, the lifestyle baseline is different. And while access is high, lifestyle-related diseases (e.g., metabolic issues from long hours and convenience food) are rising.
As for #3, I have had at least a couple MRIs and CT scans, and they were all under 100 bucks, I'm sure. I always walk in off the street, and I am seen within 30 minutes if it's busy, usually quicker. There are just so many doctor's offices, mid-sized clinics or "hospitals," and the full-on hospitals.
At a regular clinic (while there are 3-4 places right in the same building or adjacent buildings), I walk in because I have a shoulder problem, say. They take my name, I sit, I go in to see the doctor within 5-10 minutes. He asks me about it, checks it out, then orders an X-ray. I go down the hall to where they have the machine as the nurse gets me X-rayed. I wait another 5-10 minutes, and then I go in and he tells me what's up. He might send me to physiotherapy right then and there--in another room. I pay 12 bukcks and leave. Oh, not without my prescription, which I take to the pharmacy downstairs. I get medicine for a few days. 8 bucks, maybe.
At a mid-sized "hospital" specializing in bones, I went in a couple years ago for my left knee. There's been some bump-thing on it since university days, and it bothers me only sometimes. But lately, it had been to where I thought I might need surgery. I walk in--off the street, no appointment--give my name, wait 20 minutes or so, and then see the guy. He orders an X-ray (or MRI??), I go down, wait a bit, get it, then wait again and see him once more. (There are about 100 people or so in the whole place, and they are all being circled around efficiently to different stations of sorts, so this is a but more waiting than at a smaller clinic.) Then I'm in, and he's telling me I have bipartate patella (knee is in two parts rather than a single bone), have always had this, and that it's fine, yet I could do some options of surgery if I like. I got some medicine and the pain went away over some time. That one didn't cost me more than 100 dollars, I'm sure.
As for definite MRI and CTs, I do recall for various things being in a whirring machine for my head (MRI), and CT scans for my stomach (and maybe other things. My wife knows more about my history than I do due to my aging and muddled memory combined with everything always being in Korean.) But it's never more than a couple hundred dollars with the most extensive tests, consulting, and treatment.
Again, I do not know how it all works, and they have achieved sime kind of excellent balance of free markets and government, but I expect if all the related markets in healthcare were freer, it would be even better. But as is, it is state of the art and affordable.
Dentist's, too. I go there and get the most high-tech treatment I've seen. I get regular cleanings for 15 bucks (with an appointment!). Afterward, they go through my X-rays (oh, yes, X-rays just before cleaning) and tell me what's going on, making some recommendations, which I can take or leave.
I simply do not worry about healthcare. I will go in for anything without fear of cost. it's all upside, as the initial consulting and testing is gonna be nothing which puts me out in any significant way.
As for Point 5, I can attest that yes, people are in all the time. I think it's partly the volume that allows all these places to stay in business, making small "sales" on people coming in for everything and paying peanuts. 23 years ago, when I first came here, I was always alarmed when students would say that on the weekend they had been to the "hospital." I was always like, "Oh, dear! What happened?" "I had a cold." They just mean that they went to the doctor's office. But that's it. They go there for colds, cuts, whatever pain, etc. I can walk in with an upset stomach due to food poisoning (I'm sometimes a miss on some shellfish!) and find myself on an IV for an hour within minutes. Go off home feeling better and 15 bucks lighter in the pocket.
I don't know what else to tell you. I'm almost always off the street, no phone-in or appointment. It's always top notch, and it's always affordable. It is literally unbelievable to Canadians. Healthcare is the least of my worries in Korea.
Excuse me for the rambling answer!
It was very interestingly rambling :) Thanks for the details!
So I assume it's subsidized heavily, co-pays are low, but not zero, and somehow it seems the capacity is well above utilization (so queues don't really have a chance to form, or back up).
https://www.macrotrends.net/global-metrics/countries/kor/south-korea/healthcare-spending so it's increasing as a percentage of GDP (which is not really surprising considering an aging population, but above OECD average)
https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(24)00263-3/fulltext
"""
Despite a shift toward greater public funding—with public expenditure comprising 64.4% of total spending in 2020—OOP payments still accounted for 35.6%, remaining above the OECD average. Individuals aged 60 and above contributed to 51.3% of total expenditures.
"""
https://freopp.org/south-korea-22-in-the-2024-world-index-of-healthcare-innovation/
"""
The South Korean system is funded through contributions that are proportional to taxpayers’ wages, with the current contribution rate standing at 6.67 percent of monthly income, slightly up from previous years.
[...] high doctor-to-population ratio with 2.6 doctors per 1,000 people as of 2023, which represents an increase that improves access and reduces wait times. Hospital bed availability is also notable at 12.3 beds per 1,000 people, one of the highest rates globally, reflecting the country’s readiness to manage both acute and long-term care needs.
[...] Its infrastructure ranking remained at 31st, in part because the country is wasting excess hospital capacity but also lacks enough primary care doctors.
"""
https://jkms.org/DOIx.php?id=10.3346/jkms.2025.40.e121
The ratio of current medical expenses on GDP is projected to increase significantly, reaching approximately 20.0% in 2060 from 9.7% in 2024.
[...]
Health insurance rates are expected to rise steadily from 7.09% in 2024 to 14.39% by 2060.
"""
Very interesting numbers.
Yes! One of the obvious problems is the artificial constraints on the supply of doctors. This includes limited residency slots, certification of immigrant doctors who studied abroad, the requirements for entering medical school (why do you need a pre-med degree?) etc.
Of course there are many other issues but it seems obvious that these artificial constraints on the supply of doctors increase the price of their services.
Two important places to start: 1- serious long-term health insurance (as you suggested)
2- some kind of collective (as opposed to the G word) action to get the healthcare system to pay its own people better and give them better physical/mental support and working conditions. They constitute almost 15% of the US workforce, and are mostly (yes, not the folks at the top - not just insurance but also "nonrofit" hospital systems) underpaid and stressed out. Use the cost-savings of AI to treat caregivers better, and they will treat patients better and stick around longer. This could be as positive and norm-setting a move as Henry Ford's paying his car workers $5 an hour...
> Use the cost-savings of AI to treat caregivers better [...]
Can you give examples of cost-savings due to AI?
It seems that the fundamental problem of more demand for healthcare vs. cost of healthcare is not really solvable without either drastically increasing the productivity of the providers and/or reducing the demand (through magical "lifestyle" changes - ie. more walking less driving, more veggies fewer calories, more fasting less feasting, more comfort less comfort food -- and all of this kind of depends on having disposable income, the financial freedom factor of fitness, healthy wallets healthy voters, woah, I know).
Yes, which is why I'm suggesting that the HC ecosystem start with its own people - employees, not just patients! And meanwhile, AI can indeed save costs and improve efficiency for a lot of routine tasks, freeing the employees to focus on the meaningful, human-centered part of their jobs. For examples, look at HC use of AI in all kinds for routine tasks, from logistics to scheduling to EHR analysis (presented to clinicians who still make decisions and talk with patients). And AVOID automated claim denials :)
I started a substack and I plan to continue writing about this. I am preparing for my dissertation defense now so I do not have a lot of time to write now but I plan to lay out how the healthcare system is designed to stifle creative destruction and then ultimately what can be done about it.
I think you're right that medicine needs voices that call specifically for freedom to exchange services. The root of it is deeper than cost issues, dismantling of doctor/patient relationships, and obfuscation of the typical supply-and-demand economies by insurance and regulation. There is also a real doctor shortage. There are controls on new practices - who can open them where they can be opened. There are issues with licensing (and over licensing). Plus all of the your list above, Jason. The regulation on the medical complex in the US is truly mind boggling.
However, a major, overarching issue is that most people are arguing from a pragmatic perspective for some version of more or less government involvement in healthcare because:
1. They don't believe that consumers of health care behave (or would or can behave) as consumers in other industries. They think there is something fundamentally different about the need for healthcare that changes this equation.
2. The moral argument for freedom of exchange (between doctors and patients and any other healthcare actor from all 11 sides of the market--as Dave G said) always bumps up against the question of how we take care of poor people.
I think we really have to start showing how patients, doctors, drug companies--all of us including poor people--are hurt in myriad ways by the status quo.
The entity mostly responsible for dismantling the doctor-patient relationship has been Government Intervention.
At the time of WW2, the government under president Roosevelt instituted a freeze on wages. Health insurance became an important part of bargaining for employees' benefits.
The employers started to offer insurance coverage. When people left their jobs, if they had medical conditions, became uninsured. The government took more control with the institution of Medicare and Medicaid in the 60ties. The prices escalated and we got the DRGs (diagnosis-related groups, with caps on payments.)
Today we have ICD10 codes which are so complicated that new categories of jobs have been created to get them right. Often doctors and Hospitals do not get paid because of it. The hospitals want to discharge patients before the money (from the DRG fixed price) runs out. To this end, they hire hospitalists, intensivists, etc, who take over patients’ care the moment they set foot in the hospital.
Today the average patient is cared for by a concierge doctor when the patient is well. (doctors are so busy with managed care and mandatory electronic medical records they cannot even talk to patients, let alone examine them.) As soon as the patient sets foot in the hospital, a doctor who doesn’t know him from Adam takes over his care to make sure that costs are contained.
As a cardiologist, this happened often to my patients, who desperately called me to the hospital to take care of them (which I did without a concierge price)
This is very simplified, but make no mistakes, government regulations are the source of this evil, not insurance companies or employers.
You’re absolutely right about the end-of-life expenses. This is a consequence of the detachment of the payer from the consumer, originating from the above-described mess.
As a co-founder of AFCM (American for Free Choice in Medicine) I’ll be happy to discuss more.
Yes!! I’ve been one campaigning against the worst inefficiencies of the system!
In fact, I just published an article making the case for investment in digital infrastructure as a way to both reduce administrative bloat, and improve patient experience/health outcomes.
Another commenter mentioned Korea, they have a nationalized health app which consolidates health records and information. Anyone is able to view their record, and it is accessible to pharmacists, clinicians, billing… everyone who would need it. Similar infrastructure exists in Denmark, and Portugal.
https://open.substack.com/pub/chriselarsen/p/terms-of-care-part-3-bits-bytes-and?r=4xbr25&utm_medium=ios
I’ve been calling out the fragmentation of EHR in the US, and how the CURES act and TEFCA sound like we’re moving in the right direction, but don’t incentivize the things we really need.
Great to hear other people talking about this, look forward to reading more of your work!
Here’s a fascinating article on the history of healthcare reform movements and their failures:
https://pmc.ncbi.nlm.nih.gov/articles/PMC1447696/
Surely the YIMBY movement for healthcare would be “socialised medicine is good, actually”? (SMIGA? Hrm, not massively catchy).
Countries with national healthcare outperform the US, delivering better outcomes for less money.
Like avoiding gun deaths, and to an extent housing regulation, the barriers to this appear entirely political.
Not “surely” at all! I think socialized medicine might be more efficient than what we have today (which is the worst of both worlds) but a true free market would be far better
I came to the comment section to explain why I think there is no healthcare equivalent of yimby, but this is the perfect example.
Left and right leaning yimbys agree that any nearly kind of new housing is an improvement. Their differences exist but are less important. Left and right leaning healthcare reformers pull in opposite directions.
Example?
I don't think you want to go "true free market" in healthcare. It'll result in zero treatment options for people with diseases that are rare enough that there's either no value in even offering them, or the result will be too expensive for the majority of patients.
A free and competitive market would drive down costs and expand access as much as it is possible to do in the current economy, with current technology. I think you would be surprised how far that goes. For the small minority remaining who can't afford medical care, you can help them out directly. Subsidize demand if you must, but don't restrict supply.
Does "free market" mean no social support for people to get healthcare? I interpret Jason's comment as removing the intermediaries between providers and people, let the prices do their work on the supply side.
And of course if there are unexpectedly (!) magically (!!) somehow (!!??) still poor people then that's a social safety net question, there are still taxes and unemployment benefits, public funded basic research, orphan disease programs, and so on. (And there are unfortunately still death panels, after all there is going to be more demand than supply, but it would be better if insurers wouldn't have to do this implicitly through "hey, we really believe in people getting better, so here's hoping that God will fix your Type1 in 30 days, because we're not covering it more, xoxo".)
### Rethinking Healthcare: The Singapore Model and the Burden of Longevity
I believe that the current health insurance system is fundamentally flawed and in need of a complete overhaul. A more effective approach would be to adopt the Singapore model, which emphasizes mandatory savings coupled with price transparency. This system should be tempered with means-tested top-ups to the savings accounts of working-class individuals, as well as some form of emergency support. This layered approach ensures that individuals are primarily responsible for their healthcare costs, while also providing a safety net for those in need.
In this model, personal savings should form the backbone of healthcare financing for most middle-class people. The Singaporean system has demonstrated that this approach can lead to lower healthcare spending as a percentage of GDP, while still achieving a high life expectancy.
However, I must admit to a somewhat controversial perspective: I believe that people, on average, live too long. Most individuals over the age of 55 rarely contribute anything significant to civilization. By forcing people to save for their healthcare, we can mitigate the burden that the elderly place on their fellow citizens. This approach not only promotes personal responsibility but also ensures that the resources of the younger, more productive members of society are not unduly taxed to support those who are no longer contributing to the betterment of society.
Me, John Goodman, Sean Masaki Flynn, Murray Sabrin, the Insurance Collaboration to Save Lives, others ...
Any links I can check out?
https://www.amazon.com/Cure-That-Works-Worlds-Quarter-ebook/dp/B07MZB96Q3/ref=tmm_kin_swatch_0
https://en.wikipedia.org/wiki/John_C._Goodman
https://murraysabrin.substack.com/p/open-letter-to-bill-gates
https://www.insurancecollaborationtosavelives.org/
https://thedailyeconomy.org/article/we-dont-have-a-real-market-for-health-care-in-the-u-s/
We're here, Jason. Have been for decades. Nobody pays attention.
Who?
"disintermediated"? ITYM "disimmediated". Or "intermediated".
https://www.merriam-webster.com/dictionary/disintermediation
Optimism is the key to unlocking a healthier future, and optimistic leadership must rise to meet the challenge of transforming healthcare. We need bold voices to say "yes" to access, affordability, and patient empowerment. This field is wide open for infectious optimists to step in, shift the narrative, and build a system worthy of our highest hopes.
There are and have been a lot of people lobbying for disconnecting health insurance and employment. I think you’ll find them in the category of “progressives” or “liberals”.
So to answer your question of “where are they” the answer is “right here all along”.
So maybe the next obvious question is an important one.